Workflow GuideEndocrinology

Endocrinology APCM Patient Enrollment: A Step-by-Step Guide

Streamline APCM enrollment for Endocrinology practices. Automate diabetes and thyroid patient outreach, consent, and monitoring with AI-powered workflows.

Scaling Advanced Primary Care Management (APCM) in an endocrinology practice requires a systematic approach to identifying and enrolling high-risk diabetic and thyroid patients. By leveraging AI-driven call automation, practices can efficiently manage the high-touch requirements of insulin titration and metabolic monitoring without overwhelming clinical staff.

The Challenge

Endocrine practices often struggle with the manual labor required to enroll APCM-eligible patients, leading to missed revenue and gaps in chronic care for patients with complex metabolic needs like Type 2 Diabetes, obesity, and adrenal conditions.

Step-by-Step Workflow

1

Identify APCM-Eligible Candidates

Utilize EHR filters to isolate patients with two or more chronic conditions, typically focusing on the intersection of Type 2 Diabetes, hypertension, and obesity. This provides a high-priority list for APCM enrollment outreach.

Best Practices
  • Cross-reference A1C levels above 7.0% for priority enrollment
  • Include patients on continuous glucose monitors for high-touch care needs
Common Pitfalls
  • Ignoring thyroid patients who also have metabolic syndrome
2

AI-Driven Initial Outreach

Deploy AI voice agents to contact eligible patients. The AI explains the benefits of APCM, such as monthly medication adjustments, TSH monitoring, and consistent access to the care team for insulin management.

Best Practices
  • Script the AI to emphasize 'personalized diabetes coaching' to increase interest
  • Ensure the call timing respects patient schedules
Common Pitfalls
  • Using overly clinical jargon that confuses elderly diabetic patients
3

Secure and Document Verbal Consent

The AI agent facilitates the formal consent process, explaining the monthly nature of the service and any potential cost-sharing. This consent is recorded and timestamped to meet Medicare documentation standards.

Best Practices
  • Clearly state that APCM is a separate service from standard office visits
  • Confirm the patient's primary pharmacy for medication sync
Common Pitfalls
  • Failing to document the specific date and time of verbal consent
4

Initial Metabolic Health Assessment

During the enrollment call, the AI collects baseline data including current weight, hypoglycemia frequency, and adherence to insulin or levothyroxine regimens. This data is structured for clinical review.

Best Practices
  • Ask about barriers to medication adherence, such as cost or side effects
  • Record the patient's last known TSH and A1C dates
Common Pitfalls
  • Missing the opportunity to identify social determinants of health
5

EHR Integration and Care Plan Launch

The AI system automatically syncs the enrollment status and assessment data into the EHR. This triggers the creation of an APCM care plan that the endocrinologist or APC can finalize during the next review.

Best Practices
  • Use standardized templates for APCM care plans in the EHR
  • Notify the clinical pharmacist if insulin titration is required immediately
Common Pitfalls
  • Manual data entry errors when transferring call notes to the chart
6

Schedule Automated Monthly Follow-ups

Establish a recurring cadence where the AI contacts the patient every 30 days to track A1C progress, TSH symptoms, and CGM data. This ensures the 20-minute monthly requirement for APCM billing is met.

Best Practices
  • Link follow-up questions to the patient's specific metabolic goals
  • Escalate any 'red flag' symptoms like severe hypoglycemia directly to the nurse
Common Pitfalls
  • Inconsistent follow-up which leads to patient disenrollment

Expected Outcomes

1

Increased APCM enrollment rates for diabetic and thyroid patients

2

Reduced administrative burden on endocrine nursing staff

3

Improved A1C and TSH monitoring compliance through automated check-ins

4

Sustainable recurring revenue growth for the endocrine practice

5

Enhanced patient satisfaction due to consistent metabolic support

Frequently Asked Questions

The AI is designed to collect data and track adherence. If a patient reports blood sugar levels outside of their target range, the system immediately flags the record for a clinical staff member to perform a titration adjustment.

Yes, our AI call handling system uses end-to-end encryption and stores all verbal consent records in a HIPAA-compliant cloud environment that integrates directly with your EHR.

Absolutely. The workflow includes specific modules for tracking TSH lab results and monitoring for symptoms of hyper- or hypothyroidism to ensure dosage accuracy between office visits.

Ready to transform your endocrinology practice?

See how Tile Healthcare's AI call center can handle scheduling, triage, and patient communication for your practice.

Schedule a Demo
Endocrinology APCM Patient Enrollment: A Step-by-Step Guide | Tile Health